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STANDARDS FOR PRACTICEThe Nursing and Midwifery Board of Australia (NMBA) Registered Nurse Standards for Practice (2016) specify that the registered nurse ‘provides comprehensive safe, quality practice to achieve agreed goals and outcomes that are responsive to the nursing needs of people’ (NMBA, 2016, p. 4. © Nursing and Midwifery Board of Australia).

FIGURE 1–3 Steps required for transmission of microorganisms

Source: Generated using information from G. Lindsay, P. Russo, K. Ryan, S. Havers & K. Heard (2013). 5 moments for hand hygiene (3rd ed.). Retrieved from www.hha.org.au/UserFiles/file/Manual/HHAManual_2010-11-23.pdf.

Source oforganism

Organismtransferred

Organismsurvives

Lack of hand

hygiene

Contact withsysceptible

person

to a susceptible person, five sequential steps must occur (Figure 1–3):

1. Organisms are present on the patient’s skin or have been shed onto inanimate objects immediately surrounding the patient.

2. Organisms must be transferred on the hands of HCWs.

3. Organisms must be capable of surviving for at least several minutes on the HCWs’ hands.

4. Hand hygiene by the HCW must be inadequate or entirely omitted, or the agent used for hand hygiene inappropriate.

5. The contaminated hand or hands of the caregiver must come into direct contact with another patient (Lindsay et al., 2013).

One of the most effective ways to control the spread of microorganisms is to perform frequent hand hygiene with appropriate solutions and an effective technique. Lindsay, Russo, Ryan, Havers and Heard (2013) indicate that for an organism to be transmitted from an affected person

HAND HYGIENE

SECTION 1.2

LEARNING OUTCOMESOn completion of this section you will be able to:

1. Define the components of hand hygiene.

2. Identify the 5 moments for hand hygiene.

3. Identify the barriers to hand hygiene.

4. Demonstrate competency in undertaking hand hygiene.

KEY TERMSalcohol-based hand rub, 7detergent, 7hand hygiene, 7

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Pokrywka et al. (2014) found that patient hand washing reduced Clostridium difficile transmission.

THE 5 MOMENTS FOR HAND HYGIENEThe ‘5 moments for hand hygiene’ are now a national standard and it is imperative that all health care professionals learn and implement this strategy. The five moments include before and after touching an individual, before and after a procedure, and after touching the person’s surroundings (see Figure 1–4).

BARRIERS TO EFFECTIVE HAND HYGIENEHistorically health care professionals have contributed to the transmission of hospital-acquired infections from poor hand hygiene practices, so efforts have been made to identify factors contributing to this increased risk. Reasons cited for poor hand hygiene include:

● Factors related to logistics: ● Poor availability or inconveniently located sinks ● High workloads and insufficient time ● Inadequate protocols or guidelines ● Lack of scientific evidence demonstrating

relationship between hand hygiene and hospital-associated infections

● Factors associated with health care professionals: ● Poor knowledge or recognition of microbial

contamination risks ● Poor role-modelling behaviours and lack of positive

social norms ● Experience of skin irritation from hand hygiene

agents ● Perceptions of the person’s needs taking precedence

over hand hygiene ● Perceptions that glove usage negates need for

hand hygiene.

(Erasmus et al., 2009; Fagernes & Lingaas, 2009; Lindsay et al., 2013)

Other barriers to effective hand hygiene include the wearing of jewellery on fingers and wrists (e.g. rings and watches) (Gould & Drey, 2013). Wearing jewellery is known to increase the colonisation and carriage of gram negative bacteria (including enterobacteriaceae). Furthermore, fungal and bacterial growth and transmission are increased with the application of artificial nails and nail polish, as is the excessive growth (0.05 cm) of fingernails (Fagernes & Lingaas, 2009; Lindsay et. al., 2013).

Hand hygiene provides an opportunity to break the sequence of steps in spreading microorganisms. The Australian Commission on Safety and Quality in Health Care (2012) coordinates the National Hand Hygiene Initiative which strives to ameliorate infection risks associated with poor hand hygiene compliance. It commissioned Hand Hygiene Australia (HHA) to develop a manual to assist in the implementation of this initiative. The initiative involves numerous strategies including the introduction of an alcohol based hand rub within the clinical areas and the establishment of the ‘5 moments for hand hygiene’ (HHA, 2013).

WHAT IS HAND HYGIENE?Hand hygiene is the act of hand washing. It may be achieved using water and soap which may or may not contain antimicrobial properties. Effective hand hygiene may also be achieved with the use of an alcohol-based hand rub. The goal of hand hygiene is to reduce the hand-borne microorganisms and therefore reduce the risk of transferring these potential pathogens to other individuals or equipment. When a Surgical Aseptic Non-Touch Technique (see Section 1.5) is required, further washing is needed before donning sterile gloves and gowns for specific invasive clinical procedures. The purpose of the extended wash is to remove microorganisms from the nails, hands and forearms and prevent microbial regrowth.

Alcohol-Based Hand RubAn alcohol-based hand rub is a liquid, gel or foam solution which does not require water to reduce microbial contamination on hands. Alcohol-based hand rub solutions work by rapid killing of hand-borne pathogens through the evaporation of alcohol and should contain between 60–80% of ethanol (Maiwald, 2009; National Health and Medical Research Council [NHMRC], 2010a). Hand Hygiene Australia (2013) recommends that this method of hand hygiene is better than the use of traditional soap and water as it requires less time, is readily accessible, is more cost effective and results in a greater reduction of bacterial contamination compared to using soap and water in many clinical situations.

Water and Detergent Hand washing using running water and soap or other detergents works by mechanically dislocating microorganisms and other contaminants from an individual’s hand (Maiwald, 2009). Water and detergent should always be used when hands are visibly soiled, or in ungloved episodes of care with a person who has a Clostridium difficile infection or non-enveloped virus such as norovirus (HHA, 2013; NHMRC, 2010a).

UNIT 1 SECTION 1.2 HAND HYGIENE

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FIGURE 1–4 The 5 moments for hand hygiene

Source: Reprinted from Hand Hygiene: When and How leaflet, www.who.int/gpsc/5may/background/5moments/en/index.html. © World Health Organization 2016.

CLINICAL SAFETY ALERT

• Frequent hand hygiene provides an opportunity to prevent transmission of infection.

• Contamination can occur even during brief encounters with the person.

• People with latex sensitivity or allergy must not be exposed to latex gloves (either the health care professional or the person). Only nitrile gloves should be used in the vicinity.

After aprocedure

or body fluid

exposure risk

Beforetouchinga patient

Before aprocedure

Aftertouchinga patient

After touchinga patient’ssurroundings

2. Which hand hygiene product should be used while caring for Sam: alcohol-based hand rub or soap and water?

3. A nurse is performing hand washing after administering intravenous medications to Sam. Which action is inconsistent with proper technique?

a. The use of warm water to wash

b. The use of firm, rubbing and circular movements to wash

c. The use of a paper towel to scrub hands dry

d. Asking a colleague to turn the tap off

e. Washing for 10 seconds

f. Using both hand rub and water because transmission-based precautions are enacted with this person.

g. The use of a paper towel to turn the tap off

4. A student nurse asks you about the wearing of jewellery (dress ring and wrist watch) and fingernail polish in clinical areas. How do these three items affect hand hygiene?

CLINICAL SCENARIOSam Neal is a 30-year-old male with a past history of contracting hepatitis B virus (HBV) via intravenous drug taking when he was 19 years of age. He has been admitted to the emergency department with a chief complaint of right lower quadrant abdominal pain.

Critical Thinking Questions1. What role does hand hygiene play in

Sam’s care while in the emergency department?

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UNIT 1 SECTION 1.2 HAND HYGIENE

PREPARATION AND PLANNING

ACTION EXPLANATION AND RATIONALE

Consider the appropriateness of either hand rub or hand wash.

For clean hands use hand rub, and for soiled or dirty hands soap and water is required to remove contaminants.

Determine the location of sinks/running water and soap or soap substitutes.Determine if barriers exist to effective hand hygiene (including inappropriate nail length or artificial nails, presence of jewellery on wrist or fingers).

Short, natural nails are less likely to harbour microorganisms, scratch a person or puncture gloves. Removal of jewellery facilitates proper cleaning of the hands and arms.

Gather the correct equipment:• For hand rub or alcohol-based hand rub (with

60–80% ethanol)• For hand wash:

• Soap (antimicrobial)• Warm running water• Paper towels• Domestic waste bin.

The organisation of equipment promotes time management.

PERFORMING THE PROCEDURE


Hand rub with alcohol-based solution (procedure should take 20 to 30 seconds).Determine whether hands are visibly soiled or care encounter resulted in potential exposure to C. difficile infection or non-enveloped viruses; if so, perform hand wash with water and detergent instead.

Hand rub solution will not kill C. difficile or non-enveloped viruses.

Distil the volume of alcohol-based solution as directed by the manufacturer’s instructions into a cupped hand.

Various solutions from various manufacturers require different volumes of alcohol-based solution to achieve maximum effect.

Rub the hands together palm to palm. All skin areas must have contact with the solution so as to reduce microorganisms.

Rub one palm over the dorsum of the other hand with interlaced fingers. Repeat the procedure with the other hand on top.

All skin areas must have contact with the solution so as to reduce microorganisms.

Rub palm to palm with fingers interlaced. All skin areas must have contact with the solution so as to reduce microorganisms.

Rub the backs of the distal phalanges to the opposing palms, interlocking the fingers. Repeat the procedure with the other hand on top.


Rub the thumb with the palm of the other hand. Repeat the procedure on the other side.


Rub the tops of the fingers on the palm of the other hand in a circular motion. Repeat the procedure on the other side.


The procedure is complete when the hands are dry. Antiseptic effect is complete when hands are dry.

Hand wash with water and soap (procedure should take 40 to 60 seconds). Firstly, wet hands.

Soap applied directly to dry hands may damage skin.

Water as a medium facilitates soap dispersal across the skin.

Distil the appropriate volume of soap as directed by the manufacturer’s instructions into a cupped hand.

Various solutions from various manufacturers require different volumes of soap solution to achieve maximum effect.

HAND HYGIENETHE 3Ps TABLE

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Rub the hands together palm to palm.Rub one palm over the dorsum of the other hand with interlaced fingers. Repeat the procedure with the other hand on top.

The friction of rubbing the skin surface ensures soap contact.

Rub palm to palm with fingers interlaced.Rub the backs of the distal phalanges to the opposing palms, interlocking the fingers.Rub the thumb with the palm of the other hand. Repeat the procedure on the other side.

The friction of rubbing the skin surface ensures soap contact.

Rub the tops of the fingers on the palm of the other hand in a circular motion. Repeat the procedure on the other side.Rinse hands with water. The water should run from the wrist down to the fingers.

Mechanical action and the duration the soap product is on the skin promotes the removal of microorganisms.

This ensures that the water moves from a cleaner area to a more contaminated area.

Dry hands thoroughly with single use towel. Drying hands on a multiple-use towel will transfer a large volume of microorganisms back onto your clean hands.

Use towel to turn off the tap. Dispose of paper towel in non-hazardous waste bin.

Touching the dirty tap with clean hands will contaminate your hands again. Paper towels from hand washing are not considered infectious ‘clinical’ waste.

Variation: Specific hand wash for Surgical Aseptic Non-Touch Technique

Perform the hand wash with water and detergent steps as described above with the hands held above elbow level. Use circular movements to wash the forearm from wrist to elbow. Rinse fingertips to elbow with running water.

The hands are cleaner than the elbows. The water should run from the least contaminated to the most contaminated area.

Circular movements clean effectively.

Water rinses from the least contaminated area.

Each hand and forearm is dried thoroughly with an individual clean towel. Dry with a rotating motion from fingertips to elbow. A second new clean towel is used for the other hand and forearm.

A clean towel for each hand prevents the spread of microorganisms from the elbow to the other hand.

PERFORMING THE PROCEDURE (Continued)

PRIORITIES POST PROCEDURE


Examine hands for breaches in skin integrity. Early identification of breakage of the skin barrier assists in applying further barriers to protect the nurse and the person.

Source: Based on: ‘How to Handwash’. Retrieved from www.who.int/gpsc/5may/How_To_HandWash_Poster.pdf. © World Health Organization 2009. All rights reserved; and ‘How to Handrub’. Retrieved from www.who.int/gpsc/5may/How_To_HandRub_Poster.pdf. © World Health Organization 2009. All rights reserved.

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USING PERSONAL PROTECTIVE EQUIPMENT

SECTION 1.3


1. Identify situations where personal protective equipment should be used.

2. Demonstrate competency in the implementation of standard and transmission-based precautions.

KEY TERMSaprons, 11eye protection, 11gloves, 11gowns, 11personal protective equipment (PPE), 11


BOX 1–1 Use and Removal of Personal Protective Equipment (PPE)

Personal protective equipment (PPE) is used in order to ensure adequate protection from pathogenic microorganisms. The appropriate application sequence (donning) and removal sequence (doffing) of personal protective equipment is also a major consideration in infection prevention and control (see Figure 1–5). The Australian Guidelines for the Prevention and Control of Infection in Healthcare (NHMRC, 2010a) recommend the sequences to be used.

RECOMMENDATIONS Personal protective equipment (PPE) includes:

● Aprons or gowns worn to protect skin, uniforms or clothing.• Should be appropriate to the task.• Used for a single procedure or episode of care.• Removed in the area of care.

● Face and eye protection worn to protect from splashes or sprays of blood and body substances.• Should be worn when risk of splash or spray into face and

eyes exists.• May consist of surgical mask and protective eyewear.

● Gloves worn to protect contamination of workers’ hands.• Should be worn when risk of exposure to blood, body

substances, secretions and excretions exists.• May be non-sterile single-use natural rubber latex (NRL) or

synthetic (nitrile).• Must be changed between patients and after every episode

of care.

(NHMRC, 2010a)

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FIGURE 1–5 Quick summary sequence of donning and doffing PPE

Source: A, Andrey_Popov, Shutterstock; B, Stuart Cox. Pearson Education Ltd; C, Andresr. Shutterstock; D, nito. Shutterstock; E, Pearson Education Ltd; F, age fotostock/Alamy Stock Photo; G, UltraOrto, S.A. Shutterstock; H, Pearson Education Inc.

A Gown B Apron C Eye protection D Gloves



Perform hand hygiene. Hand hygiene is performed as an infection control precaution.

Consider which cares or activities are required while in the person’s room. Consider what level of infection control precautions is required. Determine which supplies are present within the person’s room and which must be brought to the room.Consider whether special strategies are indicated for removal of any specimens or other materials from the room.

This will determine which equipment is required.This will determine the type of PPE needed.

Reduces the exposure to contamination.

Gather the correct equipment:• Gown• Mask• Eyewear• Gloves.


USING PERSONAL PROTECTIVE EQUIPMENT (PPE)THE 3Ps TABLE



Remove or secure all loose items such as name tags or jewellery. Reduces the exposure to contamination.

Explain to the individual why PPE is necessary. Standard precautions are performed with all persons.

Perform hand hygiene and observe appropriate infection control procedures. Hand hygiene reduces the transmission of microorganisms.

E Surgical mask F Surgical mask with faceguard G P2 mask H N95 respirator mask

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UNIT 1 SECTION 1.3 USING PERSONAL PROTECTIVE EQUIPMENT



Apply a clean gown

• Pick up a clean gown, and allow it to unfold in front of you without allowing it to touch any area soiled with body substances.

• Slide the arms and the hands through the sleeves.• Fasten the ties at the neck to keep the gown in place.• Overlap the gown at the back as much as possible and fasten the waist ties

or belt. ❶

❶ Overlapping the gown at the back to cover the nurse’s uniform.

A clean gown is worn to prevent personal clothing coming in contact with body fluids and waste.

Overlapping securely covers the uniform at the back. Waist ties keep the gown from falling away from the body, which can lead to inadvertent soiling of the exposed uniform.

Apply the face mask

• Locate the top edge of the mask. The mask usually has a narrow metal strip along the top edge.

• Hold the mask by the top two strings or loops.• Place the upper edge of the mask over the bridge of the nose, and tie the upper

ties at the back of the head or secure the loops around the ears. If glasses are worn, fit the upper edge of the mask under the glasses. Secure the lower edge of the mask under the chin, and tie the lower ties at the nape of the neck. ❷

❷ A face mask and eye protection covering the nose, mouth and eyes.

To block skin contact with respiratory droplet secretions.

With the edge of the mask under the glasses, fogging of the lenses is less likely to occur.

• If the mask has a metal strip, adjust this firmly over the bridge of the nose. Wear the mask only once, and do not wear any mask longer than the manufacturer recommends or once it becomes wet.

Do not leave a used face mask hanging around the neck.

To be effective, a mask must cover both the nose and the mouth, because air moves in and out of both.A secure fit prevents both the escape and the inhalation of microorganisms around the edges of the mask and the clouding of glasses.A mask should be used only once because it becomes ineffective when moist.

Apply protective eyewear if it is not combined with the face mask. Protective eyewear prevents the splashing of body fluids into the eye.

Apply clean gloves

• No special technique is required.• If wearing a gown, pull the gloves up to cover the cuffs of the gown. If not

wearing a gown, pull the gloves up to cover the wrists.

Gloves protect the hands by preventing the contamination of body fluids and wastes.

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PERFORMING THE PROCEDURE (Continued)


To remove soiled PPE, remove the gloves first since they are the most soiled.• If wearing a gown that is tied at the waist in front, undo the ties before

removing gloves.• Remove the first glove by grasping it on its palmar surface, taking care to touch

only glove to glove. ❸

❸ Plucking the palmar surface of a contaminated glove.

• Pull the first glove completely off by inverting or rolling the glove inside out.• Continue to hold the inverted removed glove by the fingers of the remaining

gloved hand. Place the first two fingers of the bare hand inside the cuff of the second glove. ❹

❹ Inserting fingers to remove the second contaminated glove.

This keeps the soiled parts of the used gloves from touching the skin of the wrist or hand.

The gown area below the waist is considered contaminated, hence the ties are undone before the gloves are removed.

Touching the outside of the second soiled glove with the bare hand is avoided.

• Pull the second glove off to the fingers by turning it inside out. This pulls the first glove inside the second glove. Using the bare hand, continue to remove the gloves, which are now inside out, and dispose of them in the appropriate waste container. ❺

❺ Holding contaminated gloves, which are inside out when properly removed.

The soiled part of the glove is folded to the inside to reduce the chance of transferring any microorganisms by direct contact.

Perform hand hygiene. Contact with microorganisms may occur while removing PPE.

Remove protective eyewear and dispose of properly or place in the appropriate receptacle for cleaning.Remove the gown when preparing to leave the room.Avoid touching soiled parts on the outside of the gown, if possible.

Outside of protective eyewear is contaminated and is removed via ear pieces or headband.

The top part of the gown may be soiled; for example, if you have been holding an infant with a respiratory infection.

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UNIT 1 SECTION 1.3 USING PERSONAL PROTECTIVE EQUIPMENT



CLINICAL SCENARIORemember Sam Neal, a 30-year-old male with a past history of contracting HBV? He has been admitted to the emergency department with a chief complaint of right lower quadrant abdominal pain. Sam has been diagnosed with appendicitis and is now being prepared for surgery.

Critical Thinking Questions1. Considering Sam’s seropositive status

in relation to hepatitis B, is there any special personal protective equipment the nursing staff should be using?

2. Upon removing your gown after caring for Sam, you notice that you have blood on your arm. What would you do?



Dispose of used equipment appropriately. Correct disposal prevents exposure to microorganisms.

Perform hand hygiene. Prevents the spread of microorganisms.

If there has been any failure of the equipment and exposure to potentially infective materials is suspected, immediately follow the procedure outlined by the organisation’s policy.Ensure that an adequate supply of equipment is available for the next health care professional.

When there has been an exposure to infectious materials it is important that the nurse follows protocol to ensure that they can be monitored for a potential infection, and also be able to protect individuals, their family members and the health care team from being inadvertently exposed to infective microorganisms.

Undo neck ties. Grasp the gown along the inside of the neck and pull down over the shoulders. Do not shake the gown.Roll up the gown with the soiled part inside, and discard it in the appropriate container.

The inside area of the neck is considered clean.

The inside of the gown is considered to be uncontaminated.

Remove the mask.• Remove the mask at the doorway to the person’s room. If using a respirator

mask, remove it after leaving the room and closing the door.• If using a mask with strings, first untie the lower strings of the mask.• Untie the top strings and, while holding the ties securely, remove the mask

from the face. If side loops are present, lift the side loops up and away from the ears and face. Do not touch the front of the mask.

Discard a disposable mask in the appropriate waste container.

This prevents the top part of the mask from falling onto the chest.The mask strings are considered clean. The front of the mask through which the nurse has been breathing is contaminated.

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SECTION 1.4STANDARD AND TRANSMISSION-BASED PRECAUTIONS


1. Distinguish between indications for standard and transmission-based precautions.

2. State the guidelines for the management of health care workers with blood-borne infections.

3. Discuss the management and disposal of soiled equipment and supplies.

4. Demonstrate competency in the use of standard and transmission-based precautions.

KEY TERMSstandard precautions (SP), 16transmission-based precautions, 16

should be employed when handling blood and body secretions. Other considerations also include the promotion of cough etiquette, adherence to Aseptic Non-Touch Techniques and appropriate handling and management of waste and linen.

2. Transmission-based precautions When the use of standard precautions alone may not be sufficient to control the spread of infection. Formally known as additional precautions, these strategies may include the wearing of additional specific PPE, restricting movement of affected individuals and associated health care workers, or even allocation of an affected person to a single room with a door and, potentially, specific air-handling techniques available. Transmission-based precautions include a subset of extra strategies specific to pathogens that pose an airborne, contact or droplet transmission risk. Signage should be utilised to remind individuals approaching the affected person which added precautions should be undertaken (see Figure 1–6).

Basic principles of infection control consider that any person may be a source of or at risk from infectious agents. The Australian Guidelines for the Prevention and Control of Infection in Healthcare (NHMRC, 2010a) indicate that infection control can be achieved by a two-tiered approach:

1. Standard precautions (SP) The routine establishment and maintenance of strategies such as appropriate hand hygiene, the wearing of PPE and the appropriate disposal of sharps. These strategies


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FIGURE 1–6 Posters used to assist in compliance of transmission-based precautions: A, Droplet precautions poster; B, Airborne precautions poster; C, Contact precautions poster

Source: Australian Commission on Safety and Quality in Health Care, Standardised Infection Control and Prevention signs (February, 2012), Sydney, Australia. ACSQHC, 2016.

UNIT 1 SECTION 1.4 STANDARD AND TRANSMISSION-BASED PRECAUTIONS

C

A B

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TABLE 1–3 Selected Microorganisms and Associated Precautions

CONDITION INFECTION TYPE PRECAUTIONS

Aspergillosis (Aspergillus spp.) Fungal S

Burkholderia cepacia Bacterial C

Chickenpox and shingles (Varicella-Zoster virus) Viral C, A

Chlamydia trachomatis Bacterial S

Clostridium difficile Bacterial C

Cytomegalovirus (CMV) Viral S

Escherichia coli (Shiga toxin-producing E. coli) Bacterial C

Giardia instestinalis Protozoan S

Hepatitis A Viral C

Hepatitis B Viral S

Hepatitis C Viral S

Human immunodeficiency virus (HIV)/AIDS Viral S

Infectious mononucleosis (glandular fever) Viral S

Influenza Viral C, D

Lice (pediculosis) – head Arthropod C

Malaria Protozoan S

Meningococcal infection (Neisseria meningitidis) Bacterial D

Norovirus Viral C, D

Pertussis (whooping cough) Bacterial D

Pneumococcal pneumonia (Streptococcus pneumoniae) Bacterial D

Respiratory syncytial virus (RSV) Viral C

Rotavirus gastroenteritis Viral C

Rubella Viral D

Scabies (Sarcoptes scabiei) Arthropod C

Severe Acute Respiratory Syndrome (SARS) Viral C,D,A

Staphylococcal infection (Staphylococcus aureus) Bacterial S(C if MRSA)

Streptococcal infection (Group A) Bacterial D

Tuberculosis Bacterial A

Vancomycin-resistant enterococcus (VRE) Bacterial C

A = Airborne; C = Contact; D = Droplet; MRSA = Multiple resistance Staphylococcus aureus; S = Standard

Source: Based on material provided by National Health and Medical Research Council (2010a). Australian Guidelines for the Prevention and Control of Infection in Healthcare, 2010, p. 165, B5.2. ISBN: 1864965282.

The vast number of microorganisms and combination of precaution types can be confusing to a new graduate (Mitchell et al., 2014). Organisations will have policy and procedure documents identifying which type of precaution

is required depending on the organism involved and the stage of the individual’s disease (i.e. whether they are still infectious or not). Table 1–3 identifies the precautions associated with some selected microorganisms.

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HEALTH CARE WORKERS INFECTED WITH BLOOD-BORNE VIRUSESAs previously mentioned, health care workers have a duty of care to protect the health and safety of individuals for whom they care. Occasionally, health care workers may, themselves, be infected with blood-borne pathogens, either from workplace accidents or from exposure to pathogens outside of the work environment. The Australian National Guidelines for the Management of Health Care Workers Known to be Infected with Blood-Borne Viruses (Department of Health and Ageing [DOHA], 2012) provide principles for the infected health care worker to assist in the protection and detection, and the management and restrictions necessary to safeguard consumers of health care in Australia.

Some important principles regarding health care workers identified in this guideline include:

● Comprehensive surveillance and reporting of possible blood-borne virus transmission

● Access to confidential testing, counselling and treatment of blood-borne viruses

● Voluntary annual blood-borne virus testing of individuals who undertake exposure prone procedures

● Blood-borne virus testing of individuals following sharps injury or body fluid exposure

● Understanding of the professional and ethical responsibility to be tested for blood-borne virus and the compliance with restrictions to their working practices as required by law

● Abstinence from exposure-prone procedures* for workers with HIV, HCV–RNA positive or HBV–DNA positive

● Support for workers known to be infected with a blood-borne virus including:

● providing a work environment which minimises risk of cross-infection

● opportunities for retraining ● maintenance of the rights of the individual in

relation to anti-discrimination, privacy, industrial relations and equal employment opportunity.

* Invasive procedures in which there is a risk of direct skin contact of the health care worker with sharp instruments, needles or sharp tissue (e.g. bones and teeth or in poorly visualised body cavities).

(HIV 5 human immunodeficiency virus; HCV 5 hepatitis C; HBC 5 hepatitis B; DNA 5 deoxyribonucleic acid; RNA 5 ribonucleic acid.)

(DOHA, 2012; NHMRC, 2010b)

CLINICAL SCENARIOBack to Sam Neal, a 30-year-old male with a past history of contracting HBV. Sam has been diagnosed with appendicitis and is now being prepared for surgery.

Critical Thinking Questions1. What precautions should both the

emergency department and operating theatre staff take in relation to Sam?

2. How should body secretions, bed linen, equipment used for vital signs, one-use disposable equipment, sharps and laboratory specimens be handled?

3. Sam is now on the ward recovering from surgery. The transmission-based precautions used are in addition to standard precautions. Which of the following precautions would the nurse use in order to be consistent with infection control guidelines? Select all that apply.

a. A surgical mask at all times while in the person’s room

b. A P2 mask/respirator when within 1 metre of the person

c. Gloves for all contact with the person

d. Hand hygiene before applying and after removing gloves

e. A gown when performing a physical examination of the person

4. The nurse is assigned to care for a person on contact precautions. Which action by the nurse would require immediate intervention on the part of the supervisor?

a. The nurse changes gloves after contact with infectious material.

b. The nurse places used disposable sharps directly into designated sharps containers.

c. The nurse removes the used gown outside the person’s room.

d. The nurse places a laboratory specimen in a plastic container which has a secure lid, and the plastic container is placed in a sealed plastic bag.

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FURTHER INFECTION CONTROL CONSIDERATIONSUnless otherwise stipulated by the organisation’s policy and procedure the following information reflects common management and disposal of soiled equipment and supplies.

Management and Disposal of Soiled Equipment and SuppliesMany pieces of equipment are supplied for single use only and are disposed of after use. Some items, however, are reusable. Determine which equipment is single use and which equipment requires sterilising.

BaggingArticles contaminated, or likely to have been contaminated, with infective material – such as pus, blood, body fluids, faeces or respiratory secretions – need to be enclosed in a sturdy bag that is impervious to microorganisms, before they are removed from the person’s room. Biohazardous waste is placed in a container with special labelling, such as that shown in Figure 1–7. A single bag can be used, if it is sturdy and impervious to microorganisms, and if the contaminated articles can be placed in the bag without soiling or contaminating its outside surface.

Double-bagging is required if the above conditions are not met.

DisposalPlace disposable sharps instruments, such as scalpels, needles and lancets, directly into a hard plastic sharps container.

Place garbage and soiled disposable non-sharps equipment, including dressings and tissues, in the plastic bag that lines the waste container and tie the bag. If the bag is sturdy and impermeable (waterproof or solid enough to prevent microorganisms from moving through the barrier even when the waste is wet), a single bag is adequate. If not, place the first bag inside another impermeable bag. Some organisations separate dry and wet waste material.

Place non-disposable or reusable equipment that is visibly soiled in a labelled bag before removing it, and send it to a central processing area for decontamination. Disassemble special procedure trays into component parts. Some components are disposable; others need to be sent to the laundry or central services for cleaning and decontaminating.

LinensHandle soiled linen as little as possible, hold it away from your body and, with the least agitation possible, place it in the linen skip. This prevents gross microbial contamination of the air and contamination of persons handling the linen. Close the bag before sending it to the laundry in accordance with organisational practice. Bag soiled clothing before sending it home.

FIGURE 1–7 Biohazard alert

© tuulijumala. Shutterstock.

Laboratory SpecimensLaboratory specimen must be placed in a leak-proof container with a secure lid. In most organisations specimens are then placed in a biohazard bag. Use care when collecting specimens to avoid contaminating the outside of the container.

DishesDishes require no special precautions. Soiling of dishes can largely be prevented by encouraging persons to cleanse their hands before eating. Use of detergent and warm water safely removes microorganisms.

Blood Pressure EquipmentBlood pressure equipment needs no special precautions unless it becomes contaminated with infective material. If it does become contaminated, follow organisational policy for decontamination. Cleaning procedures vary according to whether the equipment is a wall unit or a portable unit. In some agencies, a disposable cuff is used for people placed on isolation precautions or even for all persons. Stethoscopes should be cleaned after auscultation and after use with each person in order to remove gross contamination. Dedicated stethoscopes are used when the individual is under transmission-based precautions.

ThermometersMany organisations use tympanic thermometers with disposable tips. It is common for dedicated thermometers to remain in the room with the individual who is under transmission-based precautions.

Disposable Needles, Syringes and SharpsPlace needles, syringes and sharps (e.g. lancets, scalpels and broken glass) into a puncture-resistant container (Waste Management Association of Australia, 2010). To avoid puncture wounds, use approved safety or needleless systems and do not detach needles from the syringe or recap the needle before disposal.

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Identify level of infection control procedures

THEN You need to seek assistance from another staff member, or remove PPE and perform hand hygiene, then locate the equipment, then don a new set of PPE

THEN If you have been exposed to a pathogen for all contaminated areas, articles and yourself, follow institutional policy

IF CORRECT

Remove personal items that can be contaminated

Perform hand hygiene

Undertake care

Gather all equipment

Discuss the need of PPE with the person

Apply PPE in order of mask, gown,eyewear and gloves

Remove PPE in correct order

Perform hand hygiene

Consult signage

THEN

WHAT IF I forgot something entering the room?

WHAT IF I accidently remove the PPE in the wrong order?




Perform hand hygiene. Hand hygiene is performed as an infection control precaution.

Determine the level of precaution required. All health care professionals must initiate and maintain SP. SP apply when the nurse may come into contact with body fluids, including blood, excretions and secretions (excluding sweat). Is there a need to include transmission-based precautions based on the pathogen and exposure risks?

This will determine the type of PPE needed.

What If ● ● ● Standard and transmission-based precautions What If What If What If What If

STANDARD AND TRANSMISSION-BASED PRECAUTIONS THE 3Ps TABLE

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Remove or secure all loose items such as name tags or jewellery. Reduces the exposure to contamination.

If PPE will be used, explain to the individual why this is necessary and that SP are performed with all people.

People may feel alienated, fearful or even ashamed when staff members use this equipment. Masks block facial expressions, and being touched by gloved hands feels different. The explanation will help the individual to understand that SP are used to protect both the individual and health care workers.

Perform hand hygiene and observe appropriate infection control procedures. Hand hygiene reduces the transmission of microorganisms.

Wear gloves during contact that could involve blood, body fluids, secretions, excretions and contaminated objects (see Section 1.3).

Prevents skin contact with body fluids and wastes.

Perform hand hygiene after contact with blood, body fluids, secretions, excretions and contaminated objects (linen, dressings, equipment or any items which may have come into contact with potentially infective material) whether or not gloves are worn. Perform hand hygiene after the removal of PPE.

Gloves can develop invisible holes during use. Moisture that collects on hands under gloves promotes the growth of microorganisms.Prevents the spread of microorganisms.

Wear a mask, eye protection or a face shield, and a clean, waterproof gown during the person’s care that could involve splashes or sprays of blood, body fluids, secretions or excretions (see Section 1.3).

Prevents facial contact with body fluids and wastes.Protects personal clothing from body fluids and wastes.

Ensure that objects that have come in contact with blood, body fluids, secretions or excretions are disposed of or cleaned appropriately. Check the organisation’s infection control policy and procedure manual for details regarding proper disposal or decontamination.


Place used needles and other ‘sharps’ directly into puncture-resistant containers as soon as their use is completed. Do not attempt either to recap needles or to place sharps back in their sheaths, even using two hands.

Recapping can result in a needlestick injury.

Handle all soiled linen as little as possible. Do not shake it. Bundle it up with the clean side out and dirty side in, and hold it away from yourself so that your uniform or clothing is not contaminated (soiled).


Place all human tissue and laboratory specimens in leak-proof containers. If the outside of the container becomes contaminated, place the container inside another sealable container prior to transport.




Dispose of used equipment appropriately. Correct disposal prevents exposure to microorganisms.

Perform hand hygiene. Prevents the spread of microorganisms.

Health care workers can be exposed to potentially infective materials through puncture wounds, direct contact with broken skin or wounds, or mucous membrane contact; however, contact between potentially infective material and intact skin is not normally considered a risk for transmission of infection. If accident or failure to sufficiently uphold basic principles of SP results in exposure, the nurse must immediately follow the organisation’s policies on management of the exposure incident.

When there has been an exposure to infective materials it is important that the nurse follows protocol to ensure that they can be monitored for a potential infection, and also be able to protect individuals, their family members and the health care team from being inadvertently exposed to infective microorganisms.

PREPARATION AND PLANNING (Continued)


Consider the procedures about to be performed and determine which aspects require SP. Gather all necessary equipment. Review the components of SP as indicated.

The planning of a procedure promotes nursing practice that is effective in delivery, in terms of the person’s comfort, use of resources and health care outcomes. This will determine which equipment is required.

Gather the correct equipment:• Gown• Mask. Surgical masks are generally adequate. However, for people

suspected of having certain conditions, such as tuberculosis or H1N1 influenza, a P2 mask/respirator may be required.

• Eye protection / goggles• Gloves.


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